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Patient-Centered Referral Workflow Automation
Session 260, February 14, 2019
Heather Trafton, PA-C, MBA, SVP of National MSO Operations, Steward Health Care Network
Kristin Ottariano, MSHI, Director of Medicaid Operations, Steward Health Care Network
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Heather Trafton, PA-C, MBA
Kristin Ottariano, MSHI
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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Agenda
• HIMSS Learning Objectives
• Steward Health Care Network
• The Challenge
• Steward’s Approach
• Lessons and Recommendations
• Questions
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2
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Process Improvement
System Development
Enhance & Scale
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1. Adapt a patient-focused, user-driven approach to referral portal
design
2. Construct a set of business rules to govern an automated
referral workflow
3. Design a referral process that improves patient, PCP, specialist,
and administrator experiences
4. Select the data required to support referral workflow automation
based on business requirements
5. Plan to roll out a new referral workflow to a large provider
network
Learning Objectives
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Steward Health Care Network
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Achieve the quadruple aim:
• Better care of individuals
• Better health for populations
• Lower cost
• Drive value to physicians outside of
the traditional fee for service construct
Achieve the quadruple aim:
• Better care of individuals
• Better health for populations
• Lower cost
• Drive value to physicians outside of
the traditional fee for service construct
MissionMission
• Quality Management
• Care and Utilization Management
• Accurate Risk Adjustment
• Care Coordination
• Network Governance and
Performance Management
• Quality Management
• Care and Utilization Management
• Accurate Risk Adjustment
• Care Coordination
• Network Governance and
Performance Management
How we create valueHow we create value
With the Vision: With the Vision:
For: For:
To be the top performing ACO and health planTo be the top performing ACO and health plan
Commercial, Medicare, Medicaid PopulationsCommercial, Medicare, Medicaid Populations
STEWARD HEALTH CARE NETWORK
A Clinically Integrated, Community Based ACO
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Steward Health Care Network Footprint
Davis Hospital
and Medical
Center
Salt Lake
Regional Medical
Center
Jordan Valley
Medical Center -
West Jordan
Jordan Valley
Medical Center
Mountain Point
Medical Center
Tempe St. Luke’s
Hospital
Mountain Vista
Medical Center
St. Luke’s
Behavioral Health
Center
St. Luke’s
Medical Center
Odessa Regional
Medical Center
Wadley Regional
Medical Center at Hope
Glenwood Regional
Medical Center
The Medical Center
of Southeast Texas
The Medical Center
of Southeast Texas
– Victory Campus
Southwest
General
Hospital
St. Joseph
Medical Center
Wadley
Regional
Medical Center
TX/AR/LA, 6 Local Chapters
AZ, 3 Local Chapters
UT, 4 Local Chapters
Rockledge
Regional Medical
Center
Melbourne
Regional Medical
Center
Sebastian River
Medical Center
FL, 3 Local Chapters
Trumbull Regional
Medical Center
Hillside
Hospital
Sharon Regional
Medical Center
Easton
Hospit
al
OH/PA, 4 Local Chapters
Holy Family
Hospital
St. Elizabeth’s
Medical Center
Carney
Hospital
New
England
Sinai
Hospital
Good
Samaritan
Medical
Center
St. Anne’s
Hospital
Morton
Hospital
Norwood
Hospital
Nashoba
Valley
Medical
Center
MA, 13 Local
Chapters
One of the largest ACOs in the country, SHCN has 6
regions. Each region has local chapters.
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Steward Health Care System LLC
Steward is a nationally recognized, fully integrated, healthcare system centered around
community care as a means to meet the increasing market demand for value.
33 US hospitals across 9
states, focusing on driving
value to patients through high
quality / low cost access points
of care
7,300+ beds under
management
6+ ASCs, 25+ affiliated or
owned urgent care providers;
and 42 preferred SNFs
34,000+ employees
~1,800 providers in
employed multi-specialty
group across 11 states
3000+ total employees
Approximately 500 PCPs
385 practice locations
Equal partnership between
hospitals, employed and
affiliated physicians
Highly-integrated delivery
system, health plan and
managed care contracting
entity
>1,300,000 covered lives
under value-based contracts
~5,500 contracted physicians
Nationally-recognized
population health & analytics
infrastructure
Equal partnership between
hospitals, employed and
affiliated physicians
Highly-integrated delivery
system, health plan and
managed care contracting
entity
>1,300,000 covered lives
under value-based contracts
~5,500 contracted physicians
Nationally-recognized
population health & analytics
infrastructure
Steward Hospital
Management Company
Steward Medical Group
(SMG)
Steward Health Care
Network (SHCN)
Physician-Affiliated Businesses
Steward International
Hospitals in Malta
Letter of Intent with
Croatian Ministry of
Health
eICU, Mobile Oncology (PET)
Imaging, Tailored Risk
Assurance Company
(“TRACO”)
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The Challenge
How do we quickly and efficiently refer patients to high-
quality providers in their community?
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1/3 of patients in the
United States receive a
referral each year (2 on
average for elderly
patients)
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– but many do not
result in appointments
Frustration for Patients, Providers
(1) Source:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160594/
How could SHCN improve the experience for 2+ million patients?
Fragmented and time consuming
workflow for practice staff
Spreadsheets
Fax
Emails
Portals
Frustrating experience and poor
care coordination for patients
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Poor visibility into local specialists
Inefficient staffing of referral coordinators across the system
Fragmented processes across the Steward system
Lack of comprehensive and real-time data to understand
referral patterns and service line gaps
Inability to track referral status
Steward’s Challenge
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Vision: Patient-Centered Care Coordination
• Access to a high-quality
specialist close to home
• Appointment available in a
reasonable amount of time
• Covered by insurance
PROVIDER
PATIENT
SHCN
• Provide high-quality,
coordinated care
• Efficient process that
doesn’t burden practice
staff
• Improve patient experience
• Reduce administrative
burden on our practices
• Staffing efficiency
• Monitor data and address
areas of opportunity
Steward
Health Care
Network
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Steward’s Approach
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3-Phase Implementation
PHASE 1
Process
Improvement
PHASE 2
System
Development
PHASE 3
Enhancements and
National Use Case
Extension
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Phase 1 : Process Improvement
SHCN’s initial approach focused on:
Improving provider and practice manager awareness of high-quality
specialists through an improved DoctorFinder website, local meet and
greets, marketing, and a trained and knowledgeable referral team.
Establishing centralized referral coordinators to reduce the
administrative burden on practices by identifying appropriate specialists
and processing referrals.
“Simplification” Reducing paperwork for referrals to high-quality
providers through managed care agreements.
Medical Director Oversight: Establishing a process for SHCN to review
referrals for select specialties.
Performance Monitoring: Developing reports to monitor referral
patterns, staff productivity, and service line gaps.
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Results and Room for Improvement
Persisting Challenges
• Inefficient paper process
• Providers lacked insight into
case status
• Incomplete and lagged data
• Inconsistent usage across
practices (only 20% of referrals
submitted through process)
SHCN improved the referral process, but there were persisting challenges.
Results
• 60% of PCPs utilizing centralized
referral processing (131%
increase from previous year)
• Increase in referrals to high-
quality Steward providers
• Improvement in patient
experience
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Phase 2: System Development
• Accessible to affiliated and employed providers
• Automated eligibility check to replace time-
consuming manual process
• Rules engine to allow SHCN to configure business
rules by payor, specialty, and geography
• Nudge to suggest high quality providers located near
the patient
• Allows for centralized processing
• Includes process for case review and status tracking
• Comprehensive tracking and reporting available in
real-time
• Scalable to new markets
• Improves the patient experience
Platform
requirements
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Patient
Provider
Payor
Claims
Quality/
Risk
ADT
Dashboard Reports
• Membership
• Quality
• Patient Experience
Provider Directory
Care Management
Ad Hoc Analytics
Pop Health Vendors
Underlying Architecture
Referral Platform
SHCN CENTRAL
DATA WAREHOUSE
Labs/Rx
SHCN’s Referral Platform is powered by a central data warehouse. Key data
components are: patient demographics and managed care attribution, provider
demographics, and specialist insurance credentials.
EMR
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Key Data Sources
Three data sources are critical to legitimacy, ease of use, and data
integrity/reporting:
1. Patient data: Patient demographic data is used to identify specialists
covered by the patient’s insurance and located within an appropriate
geography. Provides the option to tie back to patient utilization data or
limit submissions to patients within the data warehouse.
2. Provider data: Pre-populates information to support ease of use of
end user. Accuracy is critical to identifying appropriate specialists -
especially data on specialty and sub-specialty. Provider data also
powers the user attribution model, linking users to providers and
practices.
3. Payor data: Payor rosters identify providers in the referral circle for
each insurance plan. Accuracy is critical to classifying cases as
simplification, needs processing, or requires review.
PATIENT
PROVIDER
PAYOR
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Referral Entry
Practice staff log in to a secure URL
to submit referrals.
• Users enter member and PCP
information on a submission page.
• A type-ahead function auto-
populates fields from Steward’s
data warehouse.
• An automated eligibility check is
executed.
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Specialist Selection
• Selection: Users select a specialist by entering
specialist information or searching based on specialty.
• Results: Providers return based on distance from the
patient.
• Workflow: A rules engine classifies the referral into one
of three categories, triggering associated workflows.
“Simplification” Workflow“Simplification” Workflow
“Needs Processing” Workflow“Needs Processing” Workflow
“Requires Review” Workflow“Requires Review” Workflow
Rules Engine
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Nudge Screen
If the referral requires Medical Director review, the tool will surface specialists that meet
simplification criteria and do not require review, sorted by distance from the patient.
User gets
notification
that referral
requires review
User gets
notification
that referral
requires review
List of
suggested
providers
appears
List of
suggested
providers
appears
PCP’s
decision
PCP’s
decision
Referral is sent
to Medical
Director for
review
Referral is sent
to Medical
Director for
review
Referral is
processed with
simplification
workflow
Referral is
processed with
simplification
workflow
Choose
alternative
specialist
Dismiss
suggestions
| The referral you submitted requires review.
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Case Queue
• Submitted cases enter a
queue where users can
view all related details
and activity.
• Referral coordinators can
manage cases from end
to end within the queue
page.
• Cases can be edited,
redirected, escalated,
and shared.
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Referral Summary
The user can view, print, or fax a summary of the referral with key
information (referral number, case ID, patient information).
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Notifications
Users receive email
notifications when
there is activity on
their cases (new case
assignments, case
decisions, questions/
comments).
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Deceptive simplicity: A significant amount of work went into
distilling the business requirements into a workflow that was
as simple, clean, and scalable as possible.
Administrative – Rules Engine
SHCN controls key administrative functions, including a rules engine
and user access. A rules engine ensures referrals are handled
consistently as the network grows.
Flexibility: Rules can be configured by
• Geography
• Specialty
• Payor
• Network affiliation
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Administrative – User Access
The user management design attributes end-users to PCPs and practices
based on structured data stored in the data warehouse. This approach allows
users to view cases based on their relationship to the PCP and practice and
allows staff to cross-cover cases.
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Implementation Process
Month
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2
3
4
5
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Referral Coordinator Roll
-Out
Medical Director Roll
-Out
Product enhancements
Test Sites Roll
-Out
Product enhancements
Full Roll
-Out
Provider Education
• 6 month implementation period after initial
product development
• Phased approach to implementation allowing for
product enhancements as each user type was
added to tool
• Swift roll-out to PCP sites (6 weeks)
– General education through Provider & Practice
Manager meetings
– Face-to-face meetings with high volume practices
– Education to end users of previous referral
submission process
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Reporting & Results
• 90% of practices using the referral management tool
to submit referrals for review and processing (up from
60%)
• Average time to process referrals is <1 day if it does
not require Medical Director review and <5 days if it
does require Medical Director review
• Practice staff report ease-of-use and improved ability
to track referral results
• Improved visibility into Medical Director review
decisions, service line gaps, referral patterns, and
referral staff performance
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National Roll-Out
• SHCN is expanding nationally and building our network in
new markets
• Standard, centralized processes, and administrative
support allow providers to focus on patient care
• Critical factors:
– Cloud-based platform
– Provider data accuracy
– Local strategy
– Increasing visibility into
high-quality providers
Phase 3: Scale & Enhance
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Ongoing enhancements to benefit referring practices
Scale & Enhance
Surfacing utilization
history and claims
data to close loop on
referral
EMR integration
Direct Scheduling
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New use cases: Behavioral Health, High-Tech Radiology
Scale & Enhance
Use Case #1
Bringing Behavioral
Health care
coordination in-house
Use Case #2
Centralizing High-Tech
Radiology care coordination
during expansion
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Lessons Learned & Recommendations
Process First,
Then Technology
Vendor
Responsiveness
& Customization
Coordinated
Strategy
Provider
Adoption Focus
Patient-Centered
Process Design
